Impact of home-based management of malaria on health outcomes in Africa: a systematic review of the evidence

Hopkins H, Talisuna A, Whitty C J, Staedke S G

CRD summary

The review found that there was no conclusive evidence on the effectiveness of home-based programmes for the management of malaria in Africa. The findings appeared to be supported by the data presented, but the rather limited search and lack of information about study quality mean that it is difficult to be certain of their reliability.

Authors' objectives

To evaluate the effectiveness of home-based management of malaria in Africa.

Searching

PubMed was searched to June 2007. Search terms were provided. The reviewers handsearched the reference lists of relevant articles and of the grey literature (for example, World Health Organisation and national reports).

Study selection

Eligible studies were set in Africa and evaluated anti-malarial treatment given presumptively for febrile illness and delivered by members of the local community without formal health-care training. Studies were required to report one or more of the following outcomes: specific health indicators (for example, incidence and/or severity of malaria morbidity, mortality) and/or malariometric indicators (for example, parasite rate, haemoglobin/packed cell volume, prevalence of splenomegaly).

Participants in the included studies were people seeking or needing malaria treatment in rural areas with either seasonal or perennial malaria transmission. Geographical areas were selected as intervention or control sites. The antimalarial drug in all cases was chloroquine, which was provided free or sold by trained community health workers and administered at household level or thereabouts. The community health worker role in some cases included education of mothers. Control arms in most of the included studies received no intervention. A large number of malaria-related outcomes were reported in the review. Follow-up varied and included revisiting households every six to nine months, follow-up three to four years later and biannual surveys of parasite and antibody indicators. The duration of the intervention ranged from about two to five years.

Two reviewers independently selected the studies for the review.

Assessment of study quality

The authors do not state that they assessed validity.

Data extraction

The authors stated neither how the data were extracted for the review nor how many reviewers performed the data extraction.

Methods of synthesis

The studies were combined in a narrative synthesis. Heterogeneity precluded meta-analysis and was discussed in the text.

Results of the review

Six studies were included (n not stated): one randomised controlled trial (RCT); four controlled trials (one partially randomised); and one pre/post study.

Effectiveness in areas with mainly seasonal transmission:

An RCT (n=13,677) conducted in Ethiopia reported a significantly lower mortality rate among under-five year olds in 12 tabias (clusters of villages) randomised to receive the intervention compared with 12 control tabias (29.8 versus 50.2 per thousand, p<0.003), a reduction in the mortality rate of 40.6% (95% CI 29.2% to 50.6%). None of the other three studies that reported mortality rates found a statistically significant effect.

A controlled study in Burkina Faso (n=3,202) reported that children treated promptly with pre-packaged chloroquine and aspirin were significantly less likely to progress to severe malaria than untreated controls (risk ratio 0.47, 95% CI: 0.37 to 0.60).

A pre/post study, also in Burkina Faso, found a decrease in the proportion of malaria cases documented as severe in the first year of the programme compared to the previous three years: 3.8% (258/6,725) versus 4.9% (704/14,314), p=0.0005.

A controlled and partially randomised study conducted in 41 villages in The Gambia reported no significant findings.

Effectiveness in areas with perennial transmission:

A controlled study in two regions of the Democratic Republic of Congo (total population 28,000) reported a two-fold reduction in mean malaria prevalence and incidence and a five- to six-fold decrease in parasitological indices in the region receiving the intervention compared to the control region. However, no change in malaria mortality rates was reported and a large number of fever cases (24%) remained untreated.

A controlled study in Kenya reported no significant findings.

Cost information

A pre-post study in Burkina Faso noted that the intervention was feasible and affordable.

Authors' conclusions

The review found that there was currently no conclusive evidence on the effectiveness of home-based programmes for the management of malaria in Africa. No data were available on the use of artemisinin-based combination therapies (ACTs).

CRD commentary

The objectives and inclusion criteria of the review were clear. Only one database was searched, which may have meant that studies were missed. Steps were taken to minimise the risk of error and bias in the process of study selection by having more than one reviewer make decisions independently; it was unclear whether this also applied to data extraction. Relevant details were provided about the clinical characteristics of the included studies and heterogeneity between the studies was well addressed in the text, but study results were not tabulated in detail and no information on study quality was reported. This made it difficult to assess the reliability of the findings. The authors' conclusions appeared to be supported by the data presented, but the rather limited search and lack of information about study quality mean that it is difficult to be certain of their reliability.

Implications of the review for practice and research

Practice: The authors stated that drug regimens and delivery mechanisms of home-based malaria management programmes may need to be tailored to local conditions.

Research: The authors stated that research was needed to help inform programme development, policy decisions and implementation of home-based management of malaria in Africa. Studies should address the impact of home- and community-based treatment on malaria-associated morbidity and mortality in different epidemiological settings, especially those with perennial transmission. Outcomes should include optimal home-based management of malaria regimen, methods of supply distribution and maintenance, use of incentives, implementation in different settings, safety, sustainability and cost-effectiveness. The effectiveness, cost-effectiveness and risk of emergent drug-resistance associated with artemisinin-based combination therapies also needed to be established.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.